General Permits (718)

C
CERTIFICATION OF EXEMPTION
FROM REQUIRING A CAMA PERMIT�1
as authorized by the State of North Carolina, //ff
Department of Environment, Health, and Natural Resources and the Coastal Resources Commission
in an area of environmental concern pursuant to 15 NCAC Subchapter 7K .0203.
Applicant, Name. `
Address ,
City
Project Location (County, State Road, Water Body, etc.)
Type and Dimensions of Project
The proposed project to be located and constructed as described
above is hereby certified as exempt from the CAMA permit re-
quirement pursuant to 15 NCAC 7K .0203. This exemption to
CAMA permit requirements does not alleviate the necessity of
your obtaining any other State, Federal, or Local authorization.
A
SKETCH �. t S J
kJ
kK
Any person who proceeds with a development without the con-
sent of a CAMA official under the mistaken assumption that the
development is exempted, will be in violation of the CAMA if there
is a subsequent determination that a permit was required for the
development.
The applicant certifies by signing this exemption that (1) the ap-
plicant has read and will abide by the conditions of this exemp-
tion, and (2) a written statement has been obtained from adjacent
landowners certifying that they have no objections to the
proposed work.
Phone Number �i�✓ - ' '� (� ��
State
This certification of exemption from requiring a CAMA permit is
valid for 90 days from the date of issuance. Following expiration,
a re-examination of the project and project site may be necessary
to continue this certification.
(SCALE: & ( �. )
Applicant's signature ; (f
CAMA Off icial's.signature '
Issuing date i T
1 _1
Expiration date
Attachment: 15 North Carolina Administrative Code 7K .0203

ADJACENT RIPARIAN PROPERTY OWNER STATEMENT
I hereby certify that I own property adjacent to h f-,+ (/v Z2 1 `' , C- is
(Name of Property Owner)
property located at 2 3 ,� 2 ��Op e4—
(Lot, Block, Road, etc.)
,(
on 4 al 7- ���df , in / 'Jele"ilf-i40/ e;' �r N.C.
(W erbody) (Town and/or County)
He has described to me as shown below, the development he is prop sing at that Iocation,
and, I have no objections to his proposal.
DESCRIPTION AND/OR DRAWING OF PROPOSED DEVELOPMENT
(To be filledinby individual proposing development)
U � �as � (IC c � �4�� � �%tir►� �oc.-�C � K«��'
D O
I
Sign re
DzJ C�y /(yC�"--
Print or Type Name
-7,-) .9 - L> Ci' C 3
Telephone Number
i
Date: �,
boaf li �-

Ballard
Medical
Management Anesthesia Billing Specialists • Medical Billing Specialists
404 Ashe Street • P.O. Box 5370
Johnson City, TN 37603-5370
423-926-3442
1-800-228-0249
Fax [phone]
V
6 l lzvP� % C✓� fe a a" 3 a 9
J hae 2)R;we D), 4e
`'Y1 C
a � ci 5 �o w� � �- •Z!t e O�e �e..lo�ht, e x� %id, � �e i S
��005inci f}L�' �j2. i4�ou�-e � �,e� ��0,�4•��0� %n�
O
�., �1A��e `�Iv Ou �e�fi�1S � 7'Gtei(L /��vP�Sq•� .
(� V